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INSTITUT JANTUNG NEGARA
National Heart Institute
Management of Valvular Heart DiseaseSurgeons Perspectives
M. Azhari Yakub
Institut Jantung Negara
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INSTITUT JANTUNG NEGARA
National Heart Institute
INSTITUT JANTUNG NEGARANational Heart Institute
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National Heart Institute
PROCEDURES DONE
Expansion
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National Heart Institute
Open Heart Surgery
0200
400
600800
1000
1200
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Congenital
Isolated CABG
Isolated Valve
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National Heart Institute
Milestones in Valve Surgery
1925 SouttarClosed MitralCommissurotomy
1957 Lillehei Mitral Valve Surgery
using CPB via Rt. Thoracotomy
1961 Starr Mitral Valve Replacement
Carpentier Mitral Valve Repair
1967 Ross Pulmonary autograft
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National Heart Institute
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National Heart Institute
CHOICE OF VALVE SUBSTITUTE
Factors for consideration
Age
Expected life expectancy
Gender
Lifestyle
Socioeconomics
Comorbid factors, renal failure, etc
Etilogy of valve disease Annular size
Surgeon-patient-preferences
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National Heart Institute
REGURGITANT LESIONS
REPAIR OR REPLACEMENT?
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National Heart Institute
MITRAL VALVE REPLACEMENT
Why not replacement?
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National Heart Institute
DIFFICULTIES WITH VALVE REPLACEMENT
Compliance
Rigorous control of INR
Accelerated degeneration of bioprosthesis
Pregnancy
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National Heart Institute
VALVE REPLACEMENT
Mechanical prosthesis
Bioprosthesis
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National Heart Institute
Innovations in Mechanical Valves
Haemodynamically better
Better washout of leaflet hinge
Less thrombogenic eg ATS valve
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National Heart Institute13
1977: SJM Masters ValveIntra-annular cuffIntra-annular carbon rim
1992: SJM Masters Hemodynamic Plus (HP) valve
Supra-annular cuff allows for largerorifice
Intra-annular carbon rim
1999: SJM Regent valveSupra-annular cuffSupra-annular carbon rim,allowing for larger inner orificeRotation mechanism
completely housed within thecarbon orifice
*2002: US Approval
*2004: Japan Approval
Evolutionary Improvement
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National Heart Institute
Long term survival (30 yrs) after mechanical valvereplacements
God e Fischlein ATS 1997:63:613-91
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National Heart Institute
WARFARINIZATION
Mobidity 5 - 15% per year
Mortality 0.2 - 1% per year
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National Heart Institute
THROMBOEMBOLIC AND ANTICOAGULANTRELATED BLEEDING
Percent per year
Valve Reference Thrombo-embolism
Bleeding Total
Starr-Edwards
Miller 5.87 3.66 9.53
St. Jude Czer 2.1 2.9 5.0
Hancock Gallucci 1.8 0.4 2.2
Ionescu-Shiley
Gonzalez-Lavin
0.36 0.64 0.99
Cumulative rate at 20years
30% 30%
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National Heart Institute
BIOPROSTHESIS
2nd generation bioprosthesis
Hancock II
Carpentier-Edwards supra annular valve
Carpentier-Edwards pericardial valve (1981)
Gluteraldehyde fixed at low pressure
treated with anti-calcification solutionmounted on flexible struts
better haemodynamic
improve durability
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National Heart Institute
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National Heart Institute
Biological valves beyond 15 years
Freedom from valve failures
Edwards et al ATS 1995:60 (suppl) 5211-5
AVR
MVR
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INSTITUT JANTUNG NEGARA
National Heart InstituteFann et al. ATS 1996, 62
BIOPROSTHESIS AVR
Freedom from Structural valve deterioration with age
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National Heart Institute
DURABILITY OF BIOPROSTHESIS(HANCOCK)
At 10 years in 47% redo rate
Age is a strong determinant of durability
< 20 y.o : 50% redo rate at 10 years
40-50 y.o : 10% redo rate at 10 years
> 60 y.o : 3% redo rate at 10 years
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National Heart Institute
IfMV Replacement is unavoidableChordal apparatus should be preserved
Posterior chordal preservation
Anterior chordal preservation (possible LVOTO)
Both
Chordal reconstruction with Gore-Tex sutures
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National Heart Institute
Anterior Chordal preservationPosterior Chordal Preservation
Chordal Reconstructed withGoretex suture
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National Heart Institute
MITRAL VALVE REPAIR
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National Heart Institute
Improved survival after repair
Enriquez-Sarano et al. Circulation 1995, 91:1022-28
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National Heart Institute
Annulo-ventricular continuity
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National Heart Institute
__ Repair. Bio
--- Mech
__ Repair. Bio--- Mech
__ Repair. Bio
--- Mech
WHY REPAIR?
Actuarial Survival
Freedom from Reoperation
Freedom fromthromboembolic events
Yau, Tirone et al, JTCVS 2000, 119(1):53-61
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National Heart Institute
WHY VALVE REPAIR?
Preservation of LV function
Avoidance of warfarization
Low thromboembolic incidence avoidance of valve prosthesis
complications
- clicking, structural failure
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National Heart Institute
MITRAL VALVE REPAIR
Valves that have pliable leaflets and fairly preservedchordal apparatus are amendable for mitral valverepair.
Calcifications of annulus, leaflet and chordae arerelative contraindications.
Feasibility of repair is a structural considerationregardless of the aetiology.
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National Heart Institute
Feasibility of repair in mitral valve
degenerative > myxo > ischaemic > rheumatic
90% 40-50%
Depends on functional/structural abnormality
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National Heart Institute
Deloche et al. J Thorac Cardiovasc Surg 1990, 99:990-1002
Degenerative
Rheumatic
Degenerative
Rheumatic
Reoperation-free Event-free
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National Heart Institute
Our Experience
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INSTITUT JANTUNG NEGARA
National Heart Institute
Mitral Valve Operations IJN
0
20
40
60
80
100
120
140
160
180
200
220
92/93 94 94 96 97 98 99 2000 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10
Tissue
MechanicalRepair
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National Heart Institute
128
106
202
97
64 61
45 43
6982
99
82 81
49
134
0
50
100
150
200
250
Freq
uency
0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80
Age (years)
1997 2010
Total: 1344 pts
Median age = 27.0
Age range =2m -77 yrs
Mitral Valve Repair
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National Heart Institute
60%
19%
10% 9% 2%
0
10
20
3040
50
60
%
1
Etiology
Etiology
Rheumatic
Congenital
Degenerative
Ischaemic
Others
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National Heart Institute
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INSTITUT JANTUNG NEGARA
National Heart InstituteYakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093
F ibilit f MV R i i
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National Heart Institute
Feasibility of MV Repair inRheumatics
Feasibility of repair improved significantly
39% in 1992-2000
65% in 2001-2010 p
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National Heart Institute
30-day mortality : 2.4% (15/627)
Causes of early deaths
Myocardial failure(LCOS) 7 (1.1%)
Septicemia 4 (0.6%)
ARDS 2 (0.3%)
Malignant Ventricular Arrhythmia 1 (0.2%)
Results
Mean X-Clamp time (min): 85 37 (21-296)
Mean CPB time(min) : 11453 (42-632)
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National Heart Institute
Actuarial survival at 10 years 98.5%
Actuarial survival
Yakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093
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National Heart Institute
Freedom from re-operation
374 183 101 30 12 7
92.0% 87.3%
Freedom from re-operation at 5 years is 92.0%10 years is 87.3%
Yakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093
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National Heart Institute
Freedom from valve failure
374 183 101 30 12 7
85.6%
72.8%
Freedom from valve failure at 5 years is 85.6%10 years is 72.8%
Defined as recurrent MR >2+ and/or reoperation
Yakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093
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National Heart Institute
Univariate MultivariateVariables HR 95% CI p value HR 95% CI P valueAge
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National Heart Institute
Comparison of durability betweenRheumatics and Degenerative
Reoperation Valve Failure
Yakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093
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National Heart Institute
Deloche et al. J Thorac Cardiovasc Surg 1990, 99:990-1002
Degenerative
Rheumatic
Degenerative
Rheumatic
Reoperation-free Event-free
Mitral
Regurgitation : Changing
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National Heart Institute
Mitral Regurgitation : Changingindications for surgery
Symptomatic
Asymptomatic
deteriorating of LV function
EF < 60% end-systolic LV diam > 45mm
RV dysfuntion
EF < 30 % Hochreiter C et al. Circulation 1986 ;73:900-912
EF change from rest to exercise Rosen SE, Am J Cardiol 1994Aug 15;74(4):374-80
onset of AF
recent onset AF likely to convert after repairChua YL et al. J Thorac Cardiovasc Surg 1994, 107:408-415
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National Heart Institute
MV Assessment
Commissurotomy
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National Heart Institute
AL Peeling
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National Heart Institute
PL Thinning
PL Thinning
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National Heart Institute
AL Mobilization
AL Patching
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National Heart Institute
Pre repair Post repair
Mitral Valve
C
Mitral Valve
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National Heart Institute
Mitral ValvePre repair Post repair
Cli k di M i l l
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National Heart Institute
AORTIC VALVE
REPLACEMENT
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National Heart Institute
AORTIC VALVE RECONSTRUCTION
Techniques at our disposal :
AV Replacement
Tissue - stented
- stentless- sutureless
- Mechanical
Ross Procedure Homograft
AV Repair
TAVI - transcatheter aortic valve implantation
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UARIAL SURVIVAL IN PROSTHESIS MISMATCH
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INSTITUT JANTUNG NEGARA
National Heart InstituteRao, Circulation 2000, 102(19) Suppl.
ACTUARIAL SURVIVAL IN PROSTHESIS MISMATCHVS ADEQUATE MATCH
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S l l
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National Heart Institute
Medtronic Freestyle-Stentless
Stentless Valve
Stentless pericardium (Sorin)
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S i t tl
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Sorin stentless
subcoronary attachment.
Cli k t dit M t titl t l
http://cardiacsurgery.ctsnetbooks.org/content/vol3/issue2008/images/large/915fig22.jpeg?ck=nckhttp://cardiacsurgery.ctsnetbooks.org/cgi/content/full/3/2008/915/F12?ck=nckhttp://jtcs.ctsnetjournals.org/content/vol130/issue5/images/large/1265.05012833.gr4.jpeghttp://jtcs.ctsnetjournals.org/content/vol130/issue5/images/large/1265.05012833.gr2.jpeg -
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StentedBioprosthesis
Stentless
COLOUR DOPPLER
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STENTLESS BIOPROSTHESIS
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STENTLESS BIOPROSTHESIS
very minimal transvalvular gradient
better regression of LV hypertrophy
hence
stentless valve confers survival advantage over stented
bioprosthesis
no data on long term follow ups, degree of structuralvalve deterioration
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Perceval S Intuity 3f Enable
Sutureless Aortic Valves
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AORTIC VALVE REPAIR
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Feasibility of AV Repair
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Feasibility of AV Repair
Feasibility for AV reconstruction is limited
< 10%
Mild-moderate AR is repairable
Severe AR is for replacement
Durability of repair in severe lesions is limited.
50%-60% reoperation rate at 5yrs
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O C S G
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INSTITUT JANTUNG NEGARANational Heart Institute
10 20 30 40 50 60 70 80
PulmonaryAutograft
PulmonaryAutograft
Mechanical Valve
Homograft
StentlessBioprosthesis
StentedBioprosthesis
AORTIC VALVE SURGERY
CHOICE OF VALVE SUBSTITUTE
AGE
TAVI
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MINIMALLY INVASIVE VALVESURGERY
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Minimally Invasive Approaches
Left Minithoracotomy
Partial Sternotomy
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Mi i ll I i V l S
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Minimally Invasive Valve Surgery
Potential advantages Good cosmesis Less pain Faster recovery Less cost Less risk of wound infection
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PARTIAL STERNOTOMY -
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PARTIAL STERNOTOMY Lower
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CONCLUSION
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INSTITUT JANTUNG NEGARANational Heart Institute
CONCLUSION
Mitral Valve and its apparatus is an integral part of leftventricular function.
Current status of mitral valve surgery is to preserve themitral apparatus whenever possible in order to preserveLV function
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CONCLUSION
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CONCLUSION
Mitral Valve Repair is preferable whenever is possible. Itbetter preserves LV function and has better long termsurvival.
Current technical innovations expand possibilityand have improved durability of repair even inrheumatics
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In Aortic Position
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In Aortic Position
Aortic repair is occasionally possible
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CHOICE OF VALVE SUBSTITUTE
Factors for consideration Age
Expected life expectancy
Gender
Lifestyle
Socioeconomics
Comorbid factors, renal failure, etc
Etilogy of valve disease
Annular size
Surgeon-patient-preferences
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Thank You
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AORTIC STENOSIS
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AORTIC STENOSIS
Indication for surgery:
Symptomatic
Asymptomatic with severe AS.
AV area
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AORTIC REGURGITATION
Indications for surgery:
Symptomatic with AR
Asymptomatic with deteriorating LV, Lvesd >55mm,LV dysfunction at rest
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SEVERE AORTIC STENOSIS WHO ARE
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ASYMPTOMATIC
Extremely low risk of sudden death in absence ofantecedent symptoms.
AVR is justified in:-
evidence of LV dysfunction
women who desire pregnancy
very strenuous occupation / activities
Click to edit Master title styleAORT
IC REGURGITATION WHO IS
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ASYMPTOMATIC - INDICATION FOR AVR
1. Lvesd > 55 mm or Lves volume index > 60 ml/m2
2. Evidence of progressive of LV dilatation over time
3. EF < 50%, Lvedd > 80 mm. Lvedp > 20 mm Hg
maybe helpful
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IN SEVERE AR WITH POOR LV FUNCTION /
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EXCESSIVE LV DILATATION
Surgery is helpful in this group of patients.
Klodas et al JACC 1996; 27
31 patients with Lvedd > 80 mm
- Low operative mortality - 5.6%
- 10 year survival of 73%- EF improved from 47% - 53%
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AORTIC STENOSIS IN LV DYSFUNCTION
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AORTIC STENOSIS IN LV DYSFUNCTIONMayo Clinic (Connolly et al)
154 patients with EF of 35%
Operative mortality of 9%
5 yr survival 69% (cf 77% in good EF) EF improved in 70% of cases from EF 27%
to 39%
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AORTIC STENOSIS IN THE ELDERLY
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AORTIC STENOSIS IN THE ELDERLY
Operative mortality in octogenarians : 5 - 15%
AVR in elderly is underuse
Consider co-morbid factors
Use of bioprosthesis
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PROBLEMS
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PROBLEMS
Aortic Stenosis with low press gradient with poor LV function
To distinguish between:
a. Severe AS with poor EF - surgery will benefit
b. Moderate AS with concurrent primary myocardial dysfunction
- surgery will not benefit
Test:
1. Dobutamine stress echo
a. if fixed valve area with stroke volumeb. if valve area with stroke volume
2. Assess degree of valve calcifation
Click to edit Master title styleMILD
TO MODERATE AORTIC STENOSIS IN
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PATIENTS UNDERGOING CABG
Recent prospective studies : 75% of patients
develop symptoms
requiring AVR within5 years
Repeat surgery for AVR was high mortality : 14 - 30%
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Y PLACE IN PROPLYLACTIC AVR ATTHE TIME OF CABG?
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National Heart Institute
THE TIME OF CABG?
Baseline aortic jet velocity progression of symptoms
Velocity < 3.0 m/s 5 yr event free survival 84%
no AVR needed
Velocity > 4.0 m/s 5 yr event free survival 21%
need AVR
Intermediate 3-4 m/s assess degree of calcificationbefore deciding on AVR
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COX REGRESSION IN INITIALLY
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National Heart Institute
ASYMPTOMATIC AS
Otto, Circulation 1997, 95
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icted survival curve in ischemic mitral regurgitationRepair vs replacement
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7/27/2019 Mandalay 13
86/87
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INSTITUT JANTUNG NEGARA
National Heart Institute
Repair vs replacement
Gillinov,CosgroveJTCVS 2001, 122(6)
A.
Good pts
B.Lateral wall abNComplex MR jet
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-
7/27/2019 Mandalay 13
87/87
y